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Medicare Secondary Payer Questionnaire

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Step 1 of 2

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This field is for validation purposes and should be left unchanged.

Patient Name*

Email*

Date*

MM slash DD slash YYYY

Date of Birth*

MM slash DD slash YYYY

Medicare statute and regulations require that all entities that bill Medicare for items or services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those items or services. Please complete the following:

Part I

Are you receiving Black Lung (BL) benefits?*

Yes

No

If yes, date benefits began*

MM slash DD slash YYYY

Are the services today to be paid for by a government research program?*

Yes

No

Are you entitled to benefits through the Department of Veterans Affairs (DVA)?*

Yes

No

If yes, has the DVA authorized and agreed to pay for your care at this facility?*

Yes

No

Is your illness/injury due to a work related accident?*

Yes

No

If yes, please provide accident information to the registration staff*

Part II

Is your illness/injury due to a non-work related accident?*

Yes

No

If yes, please provide accident information to the registration staff*

Part III

Are you entitled to Medicare based on age?*

Yes

No

Are you entitled to Medicare based on Disability?*

Yes

No

Are you entitled to Medicare based on End-Stage Renal Disease (ESRD)?*

Yes

No

Part IV

Are you currently employed?*

Yes

Yes, but retired from previous employment

No, Retired

No, but not retired

No, Never employed

If yes, Employer name*

Do you have group health coverage through your current employer?*

Yes

No

If yes, does your employer employ more than 20 people?*

Yes

No

Do you have a spouse that is currently employed?*

Yes

Yes, but retired from previous employment

No, Retired

No, but not retired

No, Never employed

If yes, Employer name*

Do you have group health coverage through your spouse's current employer?*

Yes

No

If yes, does your spouse's employer employ more than 20 people?*

Yes

No

By submitting this form I agree to the Terms of Use

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